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26840_ClinicalVisitSummary_CCDA.xml
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26840_ClinicalVisitSummary_CCDA.xml
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<?xml version="1.0" encoding="UTF-8"?><?xml-stylesheet type='text/xsl' href='http://researchservice.greenwaymedical.com/stylesheets/ccd.xsl'?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xmlns:voc="urn:hl7-org:v3/voc" xmlns="urn:hl7-org:v3">
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<title>MU2 Clinical Visit Summary</title>
<effectiveTime value="20130701110831-0400"/>
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<patientRole classCode="PAT">
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<addr>
<streetAddressLine>123 Test Ave</streetAddressLine>
<streetAddressLine nullFlavor="UNK"/>
<city>Norcross</city>
<state>GA</state>
<postalCode>30091</postalCode>
<country>US</country>
</addr>
<telecom use="HP" nullFlavor="UNK"/>
<patient classCode="PSN" determinerCode="INSTANCE">
<name>
<given>Three</given>
<family>ClinicalSummary</family>
</name>
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<birthTime value="19480409"/>
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codeSystemName="HL7v3 Marital Status Value Set"/>
<raceCode code="2106-3" displayName="White" codeSystem="2.16.840.1.113883.6.238"
codeSystemName="CDC Race Code Value Set"/>
<ethnicGroupCode code="2135-2" displayName="Hispanic or Latino"
codeSystem="2.16.840.1.113883.6.238"
codeSystemName="OMB Standards for Race and Ethnicity"/>
<languageCommunication>
<languageCode code="isl"/>
</languageCommunication>
</patient>
<providerOrganization classCode="ORG" determinerCode="INSTANCE">
<id root="2.16.840.1.113883.3.441.1.50" extension="300011"/>
<name>Cassie's OB/GYN Clinic</name>
<telecom use="WP" value="555-555-1004"/>
<addr>
<streetAddressLine>1004 Healthcare Dr. practice</streetAddressLine>
<streetAddressLine nullFlavor="UNK"/>
<city>Portland</city>
<state>OR</state>
<postalCode>97005</postalCode>
<country>United States</country>
</addr>
</providerOrganization>
</patientRole>
</recordTarget>
<author typeCode="AUT" contextControlCode="OP">
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<country>United States</country>
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<assignedPerson classCode="PSN" determinerCode="INSTANCE">
<name>
<given>AD008</given>
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</name>
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<country>United States</country>
</addr>
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<streetAddressLine>1004 Healthcare Dr. practice</streetAddressLine>
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<city>Portland</city>
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<country>United States</country>
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<name>Cassie's OB/GYN Clinic</name>
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<city>Portland</city>
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<postalCode>97005</postalCode>
<country>United States</country>
</addr>
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</assignedEntity>
</informant>
<custodian typeCode="CST">
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<name>Cassie's OB/GYN Clinic</name>
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<city>Portland</city>
<state>OR</state>
<postalCode>97005</postalCode>
<country>United States</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<legalAuthenticator>
<time value="20130701110831-0400"/>
<signatureCode code="S"/>
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<country>US</country>
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<telecom use="WP" nullFlavor="UNK"/>
<assignedPerson classCode="PSN" determinerCode="INSTANCE">
<name>
<given>AD008</given>
<family>AD008</family>
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</assignedPerson>
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</legalAuthenticator>
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<code code="-1" displayName="Proctologist" codeSystemName="GMTDynamic"/>
<assignedPerson classCode="PSN" determinerCode="INSTANCE">
<name>
<given>James</given>
<family>Ingram, M.D.</family>
</name>
</assignedPerson>
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<performer typeCode="PRF">
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<code code="-1" displayName="Pain Management" codeSystemName="GMTDynamic"/>
<assignedPerson classCode="PSN" determinerCode="INSTANCE">
<name>
<given>Henry</given>
<family>Seven, M.D.</family>
</name>
</assignedPerson>
</assignedEntity>
</performer>
<performer typeCode="PRF">
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<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="UNK"/>
<code code="-1" displayName="Gastroenterologist" codeSystemName="GMTDynamic"/>
<assignedPerson classCode="PSN" determinerCode="INSTANCE">
<name>
<given>Penny</given>
<family>Puffer, M.D.</family>
</name>
</assignedPerson>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<component>
<structuredBody classCode="DOCBODY" moodCode="EVN">
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<section classCode="DOCSECT" moodCode="EVN">
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<code code="29299-5" displayName="Reason for Visit"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Reason for Visit</title>
<text mediaType="text/x-hl7-text+xml">Not available.</text>
</section>
</component>
<component>
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.2.6.1"/>
<id root="2.16.840.1.113883.3.441" extension="2ec5100632464265"/>
<code code="48765-2" displayName="Allergies, adverse reactions, alerts"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Allergies and Adverse Reactions</title>
<text mediaType="text/x-hl7-text+xml">Not available.</text>
</section>
</component>
<component>
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
<id root="2.16.840.1.113883.3.441" extension="24df5252f7494583"/>
<code code="8716-3" displayName="Vital signs" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"/>
<title>Vital Signs</title>
<text mediaType="text/x-hl7-text+xml">Not available.</text>
</section>
</component>
<component>
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.2.38"/>
<id root="2.16.840.1.113883.3.441" extension="dd85720684cc4176"/>
<code code="29549-3" displayName="Medications Administered"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Medications Administered</title>
<text mediaType="text/x-hl7-text+xml">Not available.</text>
</section>
</component>
<component>
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
<id root="2.16.840.1.113883.3.441" extension="70c7cc994fe54853"/>
<code code="10160-0" displayName="History of medication use"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Medications</title>
<text mediaType="text/x-hl7-text+xml">Not available.</text>
</section>
</component>
<component>
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.2.2.1"/>
<id root="2.16.840.1.113883.3.441" extension="dd7fa6c793fa449d"/>
<code code="11369-6" displayName="History of immunizations"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>History Of Immunizations</title>
<text mediaType="text/x-hl7-text+xml">Not available.</text>
</section>
</component>
<component>
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
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extension="33c95a786ec04d2c"/>
<code code="47519-4" displayName="History of procedures"
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>History of Procedures</title>
<text mediaType="text/x-hl7-text+xml">
<table border="1">
<thead>
<tr>
<th>Date Ordered</th>
<th>Description</th>
<th>Order Status</th>
<th>Result Status</th>
</tr>
</thead>
<tbody>
<tr>
<td
ID="ref_2170a013ee4f4afebcc4ac2bbfd2bc2a_procedure_dateOrdered_1"
>3/20/2013 12:00 AM</td>
<td ID="ref_2170a013ee4f4afebcc4ac2bbfd2bc2a_procedure_name_1"
>Lipid panel</td>
<td
ID="ref_2170a013ee4f4afebcc4ac2bbfd2bc2a_procedure_orderStatus_1"
>Ordered</td>
<td
ID="ref_2170a013ee4f4afebcc4ac2bbfd2bc2a_procedure_resultStatus_1"
/>
</tr>
<tr>
<td
ID="ref_2170a013ee4f4afebcc4ac2bbfd2bc2a_procedure_dateOrdered_2"
>3/20/2013 12:00 AM</td>
<td ID="ref_2170a013ee4f4afebcc4ac2bbfd2bc2a_procedure_name_2"
>Lipid panel</td>
<td
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<td
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<code code="10164-2" displayName="HISTORY OF PRESENT ILLNESS"
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<title>History of Present Illness</title>
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<table border="1">
<thead>
<tr>
<th>Diagnosis</th>
<th>Date</th>
</tr>
</thead>
<tbody>
<tr>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_diagnosis_1"
>Abscess Of Breast Associated With Childbirth</td>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_date_1"
>03/20/2013</td>
</tr>
<tr>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_diagnosis_2"
>Atrophy Of Breast</td>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_date_2"
>03/20/2013</td>
</tr>
<tr>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_diagnosis_3"
>Fat Necrosis Of Breast</td>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_date_3"
>03/20/2013</td>
</tr>
<tr>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_diagnosis_4"
>Fibroadenosis Of Breast</td>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_date_4"
>03/20/2013</td>
</tr>
<tr>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_diagnosis_5"
>Fibrocystic Mastopathy</td>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_date_5"
>03/20/2013</td>
</tr>
<tr>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_diagnosis_6"
>First Degree Burn of Breast</td>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_date_6"
>03/20/2013</td>
</tr>
<tr>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_diagnosis_7"
>Fissure Of Nipple</td>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_date_7"
>03/20/2013</td>
</tr>
<tr>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_diagnosis_8"
>Malignant Neoplasm Of Female Breast</td>
<td
ID="ref_9f2173a9a20b4b7989001f10616bca5e_presentIllness_date_8"
>03/20/2013</td>
</tr>
</tbody>
</table>
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